Healthcare Provider Details

I. General information

NPI: 1073871596
Provider Name (Legal Business Name): PHYLLIS NUGENT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13687 N LAKEVIEW DR
LEWISTOWN IL
61542-9258
US

IV. Provider business mailing address

13687 N LAKEVIEW DR
LEWISTOWN IL
61542-9258
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-2779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.393497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: